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Injuries: Boys vs Girls

Soccer May Be Safer Than Football, But After Age 12 the Game Heats Up And So Does the Risk of Getting Sidelined

It's nearly impossible to tune into the World Cup and not cringe at the knocked heads and kicks to the chest. Concussions, knee injuries and ankle sprains are common in kids' soccer, too, though the sport is still safer than kids' football and rugby.

What's more, girls and boys suffer different types of injuries. Girls are more prone to heat illness and concussions. And in a new study that has puzzled researchers, girls are more likely to tear a ligament on their supporting leg, whereas boys are more prone to injure their dominant leg.

Experts attribute the disparities to different physiologies and styles of play. Some believe girls are simply more forthcoming with their symptoms.

Meanwhile, soccer safety regulations and equipment have changed little since the sport was popularized in the U.S. after World War I. Shin guards, for example, have long been required, but years ago were sometimes constructed of cardboard, leather straps or even magazines, says Mark Koski, assistant director of the National Federation of State High School Associations, which oversees high school sports nationwide. In 2008, the NFHS updated its standards for shin guards and now they must be certified by the National Operating Committee on Standards for Athletic Equipment.

Efforts to require soccer helmets, notably in Massachusetts, have failed to gain traction.

Orazio Siclari of North Haledon, N.J., has a 14-year-old daughter and a 15-year-old son who both play team soccer. His son, Sebastian, has had a few muscle strains. His daughter, Olivia, broke her nose six weeks ago and suffered a concussion while playing last year.

"Fortunately it wasn't that advanced, but it's still disturbing when your kid is saying her head hurts and she doesn't feel good," Mr. Siclari said of Olivia's concussion.

Most injuries, like Olivia's, occur in competitions rather than in practices—3.9 times as many for boys and 4.6 times as many for girls, according to the Center for Injury Research and Policy at National Children's Hospital in Columbus, Ohio. For both genders, about twice as many injuries occur in the second half, when fatigue sets in. No position on the field has been consistently found to be riskier, but about a third of injuries occur at the top of the goal box.

More than eight million American youths play soccer in school and community leagues, according to the Sporting Goods Manufacturers Association. For the youngest soccer players, injuries are rare and minor because the game is slower and less intense. That all changes after age 12, when the casual players tend to drop out and the onset of puberty amps up the level of play, says Donald Kirkendall, a sports medicine researcher at the University of North Carolina.

That's also when injury patterns diverge for boys and girls, as their bodies begin developing differently.

More boys tend to hurt their ankles, while girls tend to hurt their knees. Studies have found that adolescent girls are four to six times more likely to tear their anterior cruciate ligament, found in the back of the knee, than boys of the same age, according to the Council on Sports Medicine and Fitness. Scientists are not sure why, but believe estrogen makes girls' ligaments looser, and lower levels of testosterone make it harder for girls than boys to build muscle. Also, because girls' muscles are different sizes and proportions compared to boys, Dr. Kirkendall says girls tend to stay more erect when they land, which absorbs less shock and can cause their knees to buckle.

A study published this month in the British Journal of Sports Medicine found that boys tend to injure the ACL in their dominant kicking leg, whereas girls are more prone to injuries in their supporting leg. The authors said more research was needed to understand why.

Girls are also more susceptible to heat illness, according to a 10-year study of participants in the Schwan's USA Cup, the largest youth soccer tournament in the Western hemisphere. In the two years when the heat index topped 84 degrees, girls were 1.7 times more likely to suffer heat illness—exhaustion, hyperventilation or cramping—than their male counterparts. (Both years officials shortened playing time, required water breaks and allowed unlimited player substitutions.)

Researchers aren't sure why girls are more likely to suffer concussions, but theorize it's because girls' neck muscles are not as strong or because they are more likely to report their injuries. Most concussions result from collisions with another player, not from heading the ball, says Matthew Grady, a pediatric sports medicine specialist at the Children Hospital of Philadelphia.

Most leagues require players who show symptoms of concussions (such as loss of consciousness, headache, dizziness, confusion or balance problems) to be cleared by a medical professional before returning to the field. The practice became an official rule of the NFHS this past school year.

To prevent injuries, teams should stretch and warm up at the beginning of every practice. Coaches and trainers are advised to emphasize correct posture, straight up-and-down jumps, minimal side-to-side movements and soft landings (on the balls of the feet with a bent knee and straight hip). Research has shown that proper training and conditioning can reduce the risk of ACL injury, often by 30%.